Cycle 1
Health 2024-11-26 · Fire 2024-11-26
9 health deficiencies
Top issue: Resident Rights (3 deficiencies)
5 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Golden, IL
Golden Good Shepherd Home
3-star overall rating with 3-star inspections with 9 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
101 Prairie Mills Road, Golden, IL
(217) 696-4421
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
46
Certified beds
Average residents
31
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2007-07-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.65
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.86
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.04
Nurse aide staffing · state 2.13 · national 2.35
Total nurse hours
3.55
All reported nurse hours · state 3.49 · national 3.89
Licensed hours
1.52
RN + LPN hours · state 1.36 · national 1.54
Weekend hours
3.06
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.46
Weekend registered nurse coverage · state 0.56 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.73
CMS adjusted RN staffing hours
Adjusted total hours
4.00
CMS adjusted total nurse staffing hours
Case-mix index
1.22
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
41%
Annual nurse turnover · state 46% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,755
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
10.66
Composite VBP score used to determine payment impact.
Payment multiplier
0.9809
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Performance 21.88% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
0
Performance 7.73% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
3.03
Baseline 55.88% · Performance 51.28% · Measure score 3.03 · Achievement 3.03 · Improvement 0.98
Adjusted total nurse staffing
1.23
Baseline 4.02 hours · Performance 3.43 hours · Measure score 1.23 · Achievement 1.23 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.48% |
10.72%
0.2 pts better
|
No Different than the National Rate · Eligible stays 49 · Observed rate 8.16% · Lower 95% interval 6.89% |
| Discharge to community | 37.67% |
50.57%
12.9 pts worse
|
No Different than the National Rate · Eligible stays 47 · Observed rate 27.66% · Lower 95% interval 25.72% |
| Medicare spending per beneficiary | 1.14 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 92.59% |
95.27%
2.7 pts worse
|
Numerator 25 · Denominator 27 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 27 |
| Discharge self-care score | 68.18% |
53.69%
14.5 pts better
|
Numerator 15 · Denominator 22 |
| Discharge mobility score | 45.45% |
50.94%
5.5 pts worse
|
Numerator 10 · Denominator 22 |
| Pressure ulcers or injuries, new or worsened | 7.41% |
2.29%
5.1 pts worse
|
Numerator 2 · Denominator 27 · Adjusted rate 8.99% |
| Healthcare-associated infections requiring hospitalization | 7.73% |
7.12%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 32 · Observed rate 9.38% · Lower 95% interval 4.01% |
| Staff COVID-19 vaccination coverage | 1.33% |
8.2%
6.9 pts worse
|
Numerator 1 · Denominator 75 |
| Staff flu vaccination coverage | 26.74% |
42%
15.3 pts worse
|
Numerator 23 · Denominator 86 |
| Discharge function score | 59.09% |
56.45%
2.6 pts better
|
Numerator 13 · Denominator 22 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.4 |
2.0
1.6 pts better
|
1.9
1.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.4 · Observed 0.5 · Expected 2.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.1 |
2.3
0.2 pts better
|
1.8
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 2.4 · Expected 1.9 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.3% |
89.6%
8.7 pts better
|
93.4%
4.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.0% · Q2 96.9% · Q3 100.0% · Q4 100.0% · 4Q avg 98.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.1% |
91.6%
5.5 pts better
|
95.5%
1.6 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.0% |
3.3%
1.7 pts worse
|
3.3%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 9.4% · Q3 0.0% · Q4 0.0% · 4Q avg 5.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
50.3%
50.3 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 5.0% |
6.5%
1.5 pts better
|
5.4%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 7.7% · Q3 4.3% · Q4 4.0% · 4Q avg 5.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 12.5% |
18.5%
6 pts better
|
19.6%
7.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.4% · Q2 10.7% · Q3 12.5% · Q4 11.5% · 4Q avg 12.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 5.9% |
22.8%
16.9 pts better
|
16.7%
10.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.0% · Q3 0.0% · Q4 4.8% · 4Q avg 5.9% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 27.0% |
17.2%
9.8 pts worse
|
16.3%
10.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 27.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 26.7% |
15.0%
11.7 pts worse
|
14.9%
11.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.1% · Q2 40.7% · Q3 17.4% · Q4 24.0% · 4Q avg 26.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 5.0% |
1.1%
3.9 pts worse
|
1.0%
4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 6.9% · Q3 7.2% · Q4 3.8% · 4Q avg 5.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 8.6% |
1.7%
6.9 pts worse
|
1.7%
6.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 10.0% · Q3 11.5% · Q4 11.1% · 4Q avg 8.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 29.0% |
21.3%
7.7 pts worse
|
19.8%
9.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.1% · Q2 47.2% · Q3 27.7% · Q4 23.0% · 4Q avg 29.0% |
| Percentage of long-stay residents with pressure ulcers | 8.0% |
5.2%
2.8 pts worse
|
5.1%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 2.8% · Q3 10.9% · Q4 15.2% · 4Q avg 8.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 89.0% |
68.8%
20.2 pts better
|
81.7%
7.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q3 100.0% · Q4 90.0% · 4Q avg 89.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.3% |
14.0%
8.7 pts better
|
12.0%
6.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 5.3% · Observed 4.3% · Expected 9.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
2.3%
2.3 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 33.7% |
26.2%
7.5 pts worse
|
23.9%
9.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 33.7% · Observed 26.1% · Expected 18.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-09-07 · Fire 2023-09-07
4 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2022-08-18 · Fire 2022-08-18
4 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
7 fire-safety deficiencies
Top issue: Miscellaneous (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-11-26
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2025-02-01
F · Potential for more than minimal harm
2024-11-26
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-02-01
F · Potential for more than minimal harm
2024-11-26
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-02-01
F · Potential for more than minimal harm
2024-11-26
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-01-10
E · Potential for more than minimal harm
2024-11-26
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-12-18
F · Potential for more than minimal harm
2023-09-07
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2023-10-06
F · Potential for more than minimal harm
2023-09-07
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-09-12
F · Potential for more than minimal harm
2023-09-07
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-12-04
F · Potential for more than minimal harm
2023-09-07
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-09-11
F · Potential for more than minimal harm
2022-08-18
K133 · Construction Deficiencies
Fire Safety
Install a two-hour-resistant firewall separation.
Corrected 2022-10-15
F · Potential for more than minimal harm
2022-08-18
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2022-10-15
F · Potential for more than minimal harm
2022-08-18
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-10-27
F · Potential for more than minimal harm
2022-08-18
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-10-15
F · Potential for more than minimal harm
2022-08-18
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-10-15
F · Potential for more than minimal harm
2022-08-18
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-10-15
F · Potential for more than minimal harm
2022-08-18
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-10-15
Inspection history
Recent health citations
G · Actual harm
2024-11-26
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-12-21
F · Potential for more than minimal harm
2024-11-26
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-12-21
D · Potential for more than minimal harm
2024-11-26
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-12-20
D · Potential for more than minimal harm
2024-11-26
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-12-21
D · Potential for more than minimal harm
2024-11-26
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2024-12-21
D · Potential for more than minimal harm
2024-11-26
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2025-02-24
D · Potential for more than minimal harm
2024-11-26
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-02-24
D · Potential for more than minimal harm
2024-11-26
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2025-02-24
D · Potential for more than minimal harm
2024-11-26
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-02-24
F · Potential for more than minimal harm
2023-09-07
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2023-09-15
D · Potential for more than minimal harm
2023-09-07
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-09-11
D · Potential for more than minimal harm
2023-09-07
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-09-15
D · Potential for more than minimal harm
2023-09-07
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2023-09-10
D · Potential for more than minimal harm
2022-08-18
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2022-09-07
D · Potential for more than minimal harm
2022-08-18
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2022-09-07
D · Potential for more than minimal harm
2022-08-18
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2022-09-07
D · Potential for more than minimal harm
2022-08-18
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-09-07
Penalties and ownership
What sits behind the stars
$0
2024-11-26
Payment Denial
Payment Denial · denial start 2024-12-26 · 60 days
60 day denial
Ownership
Bruns, Paul
Corporate Officer · Individual
Cassens, Cynthia
Corporate Officer · Individual
Dixon, William
Operational/Managerial Control · Individual
Dixon, William
Corporate Director · Individual
Gronewold, David
Corporate Officer · Individual
Heinecke, Carl
Corporate Officer · Individual
Higdon, Britney
Operational/Managerial Control · Individual
Post, Curtis
Corporate Officer · Individual
Waite, Linda
Corporate Director · Individual
Waterkotte, Jana
Operational/Managerial Control · Individual
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